Table 3.

Selected recommendations for prevention and management of hospital-acquired, ventilator-associated, and health care-associated pneumonia

Prevent person-to-person transmission of bacteria • Use standard precautions, including hand washing, gloving for handling objects contaminated with respiratory secretions, and gowning when soiling with respiratory secretions is anticipated. • Use aseptic technique and sterilized tubes when changing tracheostomy tubes. Modify host risk factors for infection • Administer pneumococcal vaccination to high-risk patients. • Remove endotracheal, tracheal, and or/naso-enteric tubes as early as possible. • Consider noninvasive positive-pressure ventilation in place of invasive ventilation. • Perform orotracheal rather than nasotracheal intubation, unless contraindicated. • Clear secretions above the endotracheal tube cuff before deflating the cuff. • Unless contraindicated, elevate the head of the bed to 30 to 45 degrees for patients at high risk of aspiration who are receiving enteral tube feedings (note: this is typically contraindicated in patients with SCI because of risk of pressure ulcer formation secondary to skin shearing). Prevent postoperative pneumonia • Instruct preoperative high-risk patients on deep breathing exercises. • Use incentive spirometry postoperatively. • Remobilize patients out of bed as soon as medically feasible. Diagnostic procedures • Obtain chest radiographs to assist with confirming the diagnosis, assessing the severity, and ruling out associated complications such as pleural effusions. • Obtain lower respiratory tract cultures. Treatment • Initiate appropriate broad-spectrum antibiotics as early as possible. • Antibiotics should be chosen based on duration of hospitalization and the likelihood of multidrug-resistant antibiotics. • Empiric antibiotics should include agents from a different antibiotic class than the patient has received recently. • Consider narrowing the antibiotic coverage based on results of lower respiratory tract cultures and the patient's clinical response. • For patients with uncomplicated pneumonia and a good clinical response to initially appropriate antibiotic therapy, consider a shorter treatment course (7 to 8 days) in the absence of nonfermenting gram-negative rods (eg, Pseudomonas or Acinetobacter). • Perform serial assessments to monitor the clinical response. Patients who have not improved within 72 hours should be evaluated for noninfectious mimics of pneumonia, drug-resistant organisms, other sites of infection, and complications of pneumonia or its treatment, such as emphysema or clostridium difficile colitis.

Note: these recommendations are based on research performed in non-SCI patient populations. Except as noted, they are likely to apply to persons with acute or chronic SCI who have HAP or HCAP.

Data from American Thoracic Society and Infectious Disease Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171(4):388–416 and Tablan O, Anderson L, Besser R, et al. Guidelines for preventing health-care–associated pneumonia, 2003: recommendations of CDC and the healthcare infection control practices advisory committee. MMWR Recomm Rep 2004;53(RR-3):1–36.